Angiologiia i sosudistaia khirurgiia = Angiology and vascular surgery最新文献

Background: Diffuse atherosclerosis of the coronary arteries with the involvement of distal vessels, extensive calcification and a small diameter of the coronary arteries can be the reasons for refusal of invasive treatment of patients with coronary heart disease. The only option of surgical treatment for these patients is coronary artery bypass grafting, but it is associated with technical difficulties in the creation of distal anastomoses and worse long-term survival. Nevertheless, the use of microsurgical techniques makes it possible to successfully treat such patients.

Patients and methods: A 59-year-old male patient with coronary artery disease was hospitalized for elective coronary artery bypass grafting. Coronary angiography revealed a multivessel diffuse lesion with calcification of the coronary arteries. The estimated severity of coronary atherosclerosis according to the Syntax Score amounted to 39 points. Severe three-vessel distal coronary calcification was confirmed by multislice computed tomography.

Results: Using an operating microscope and artificial circulation, we performed autovenous bypass grafting of the diagonal artery, obtuse marginal artery and posterior descending artery according to the method of extended anastomoses (2 cm long) through the atherosclerotic plaque. Due to severe calcification of the anterior descending artery, 4-cm long arteriotomy was performed, followed by prolonged shuntoplasty of the arteriotomic incision of the left internal mammary artery with anterior descending artery in the area of stenosis through the calcified atherosclerotic plaque. The diameter of the target coronary arteries at the site of distal anastomoses was less than 1.5 mm. The postoperative period turned out uneventful with no complications. The patient was discharged on POD 8. In order to prevent shunt thrombosis, the patient was prescribed to receive dual antiplatelet therapy for 1 year (aspirin and clopidogrel), as well as therapy with statins (atorvastatin 80 mg). The control examination at 12 months revealed no clinical signs of ischemia return. The findings of MSCT bypass angiography confirmed patency of all shunts.

Conclusion: The use of microsurgical techniques, an operating microscope, and coronary reconstructions as shuntoplasty makes it possible to perform coronary artery bypass grafting in severe coronary artery disease with satisfactory clinical outcomes.

Mycotic (infectious) aneurysm is a rare pathology resulting from infectious destruction of the artery. Approximately 0.65-2% of aortic aneurysms in Europe are of infectious nature, in Asia this rate is higher. The most common pathogens are salmonellae (predominant in Asia) and staphylococci (predominant in European and North American patient populations) - about 40% of the total number of cultured organisms. Diagnosis is based on the clinical picture (pain, fever, sepsis), and laboratory tests include inflammatory markers. Characteristic morphological signs: baggy, sometimes multi-chambered arterial wall protrusion, perivascular edema, hematoma and/or fi brous tissue. The presence of perivascular gas and rapid aneurysm growth are pathognomonic symptoms. Currently, there is no international consensus on the optimal treatment of mycotic aneurysms, but the extremely unfavorable prognosis makes surgical treatment necessary regardless of aneurysm size. Two strategies are used - open aneurysm resection with in situ reconstruction or extraanatomic revascularization and stent-graft implantation. In both cases, prolonged antibiotic therapy is required. According to the literature, its duration should be at least 6-8 weeks, and possibly longer, up to lifelong. The main disadvantage of endovascular method is the lack of open surgical sanation of septic focus. Nevertheless, the available literature data suggest that the integral results of open surgery and X-ray endovascular techniques are comparable. It is impossible to draw statistically reliable conclusions due to the small number of observations - available clinical reports do not exceed dozens of cases. This article describes two cases of mycotic aneurysm of the infrarenal aorta. In the first case (male, 60 years old), aortic endoprosthesis was performed, followed by open sanation and drainage of retroperitoneal space and antibacterial therapy for 6 weeks (until clinical and laboratory signs of systemic infection normalized). There was no recurrence at 14 months follow-up. In the second observation (male, 62 years old), the diagnosis of mycotic aneurysm was not established. Endoprosthesis of a ruptured infrarenal aortic aneurysm was performed. Absence of massive antibiotic therapy resulted 3 months later in the manifestation of local infectious process with the development of fatal complication - aortoduodenal fistula with fatal bleeding.

In peacetime, the incidence of posttraumatic arteriovenous fistulas is relatively low. Therapeutic specialists are not, as a rule, watchful towards detecting this pathology. In atypical localizations of arteriovenous fistulas, manifestation of the disease may be in the form of signs of cardiac insufficiency. Therefore, such patients are rarely referred to a surgeon. We present herein a case of successful surgical treatment of a 40-year-old patient with a posttraumatic false aneurysm of iliac arteries and arteriovenous fistula, manifesting for many years as a clinical course of cardiac insufficiency. We performed suturing of the arteriovenous fistula and prosthetic repair of iliac arteries on the right. According to the findings of control contrastenhanced multislice spiral computed tomography, the prosthesis functions satisfactorily, with no arteriovenous shunts.

Objective: To study the possibility and determine the safety of using stent grafts with on table and in situ fenestration in patients with acute aortic syndrome.

Patients and methods: From 2019 to 2021, specialists of the Republican Cardiological Center (Ufa) retrospectively analyzed the results of endovascular treatment of 34 patients with acute aortic syndrome.

Results and discussion: All 34 patients were operated on within the first 48 hours after the disease was detected. They were subjected to various types of endovascular debranching. In 26 patients, zone 2 according to Ishimaru was selected with on table or in situ TEVAR (Thoracic Endovascular Aortic Repair) of the left subclavian artery; in 6 cases, double fenestration of the left common carotid and left subclavian arteries were performed during implantation into zone 1 according to Ishimaru. In 2 cases, total endovascular debranching was performed during implantation into zone 0 according to Ishimaru. The average operation time was 137.35±61.4 minutes, the average contrast consumption was 295.2±79.2 ml, and the average volume of blood loss was 78±121.1 ml. In all cases, the technical success was 100%, however, during the control MSCT, 2 cases of type 3 endoleaks were identified, which were further embolized. One patient developed retrograde dissection of the ascending aorta and the aortic arch 2 months after surgery. Further surgical correction was performed. Overall in-hospital mortality was 0%, and only 3 (8.8%) patients died in the remote period.

Conclusion: Thoracic endovascular aortic repair (TEVAR) of the aortic arch with various types of endovascular debranching can be considered as an alternative and effective method for treatment of patients with acute aortic syndrome.

Presented herein are two clinical case reports regarding endovascular treatment of acute myocardial infarction in patients with the new coronavirus infection COVID-19. The first clinical case report describes the development of acute myocardial infarction in a 60-year-old male patient with the novel coronavirus infection and bilateral pneumonia (60% lesion of the lung parenchyma) with neither significant atherosclerotic process in coronary arteries nor cardiovascular risk factors. Acute myocardial infarction was characterized by isolated thrombosis of the right coronary artery. In the second case report, a 72-year-old woman was diagnosed as having atherosclerotic pathology of coronary arteries with unstable plaques and a predisposition to intracoronary thrombus formation. She was found to have critical stenoses of the anterior descending and circumflex branches of the left coronary artery, uncontrolled arterial hypertension, and dyslipidemia. Discussed in the article are technical peculiarities of coronary interventions in patients with COVID-19, accompanied and followed by analyzing clinical patterns of the diseases involved.

Objective: The study was aimed at reducing the risk for the development of intraoperative embolism during thrombectomy from the iliofemoral venous segment. Danger of surgical treatment of patients with phlebothrombosis of the iliofemoral segment with flotation remains of current concern primarily due to the risk of pulmonary embolism. The authors worked out a method of surgical treatment making it possible to decrease the risk of this complication. This method was used in a total of 34 patients diagnosed with acute deep vein thrombosis. All patients, both preoperatively and in the early postoperative period, underwent chest and abdominal contrast-enhanced X-ray computed tomography, ultrasonographic duplex scanning of veins of both lower limbs. After making the fi naldiagnosis, all patients were subjected to surgical treatment: transjugular thrombectomy from the iliocaval and femoral segments, with no postoperative complications observed. All patients were discharged in a satisfactory condition to be followed up by district surgeon. The iliofemoral segment remained patent during the whole follow-up period, with no evidence of rethrombosis.

Conclusion: The developed method of transjugular thrombextraction from the iliocaval and femoral segments for phlebothrombosis makes it possible to safely restore patency of veins in the involved segment with minimal risk of both intra- and postoperative complications.

Background: There is a limited number of studies concerning the results of urgent coronary artery bypass grafting (CABG) in high-surgical risk patients with non-ST elevation acute coronary syndrome. Deficit of an evidence-supported base is related to peculiarities of organization and availability of emergency CABG, the process of decision-making, and a series of tactical and technical aspects of performing this type of intervention within the first 24 hours in high-surgical risk patients with manifest symptoms of ischemia and myocardial lesion in severe multivessel coronary atherosclerosis and involvment of the left coronary artery trunk.

Objective: The purpose of this study was to carry out a comparative analysis of the inhospital outcomes of emergency surgical and endovascular revascularization (CABG and percutaneous coronary intervention) in high-surgical risk patients with non-ST elevation acute coronary syndrome.

Patients and methods: In our retrospective study with propensity score matching, we analyzed the in-hospital results of CABG (n=67) and percutaneous coronary intervention (n=67) in high-surgical risk patients with non-ST-segment elevation acute coronary syndrome within the first 24 hours after admission. The patients had severe lesions of coronary arteries with a median of the SYNTAX score of 24 points. The endpoints of the study were all-cause mortality, cardiac mortality, myocardial infarction, repeat non-elective revascularizations, and a composite endpoint combining all the above enumerated events. Besides, we evaluated completeness of the scope of myocardial revascularization in the groups.

Results: The patients in the groups were comparable by the main clinical and anamnestic data which was ensured by propensity score matching. The majority of CABGs were performed in conditions of artificial circulation. In the group of percutaneous coronary intervention, the strategy of multivessel and staged stenting was used approximately in a similar proportion (47.8 and 52.2%, respectively). There were no significant differences between the groups of CABG and percutaneous coronary intervention by the endpoints. Mortality from cardiac causes in the groups turned out to be similar, each amounting to 4.5%. CABG was characterized by significantly higher frequency of complete myocardial revascularization as compared with percutaneous coronary intervention: n=62 (92.5%) vs n=48 (71.6%), respectively, p=0.001.

Conclusion: Urgently performed CABG demonstrated comparable with percutaneous coronary intervention in-hospital results of revascularization in high-surgical risk patients with severe multivessel lesions with non-ST elevation-acute coronary syndrome, ensuring fuller scope of myocardial revascularization as compared with percutaneous coronary intervention.

Yudin S.S. (1891-1954) outstanding physician, surgeon of the twentieth century. His achievements are associated with the development of a method for transfusion of postmortem blood to patient, reconstructive surgery of the esophagus, surgery of the stomach and duodenum, and traumatology. Yudin was encyclopedically educated, he is one of the organizers of the Academy of Medical Sciences of the USSR, he received recognition in our country (winner of two State Prizes, the Lenin Prize, member of Academy of Medical Sciences of the USSR) and the international medical community (honorary member of the Royal Society of Surgeons, etc.). In 1948-1953 he was repressed, completely rehabilitated. In 1952-1953 he was in exile in Novosibirsk, conducted research on the clinical physiology of the stomach and small intestine. In 1953 he returned from exile to Moscow and then fully rehabilitated.

Background: Currently, the approach to the management of symptomatic concomitant lesions of the carotid and coronary arteries remains controversial. No randomized trials on this issue have been conducted.

Objective: The purpose of this study was to validate the choice of surgical strategy in patients with significant symptomatic carotid and coronary artery lesions.

Patients and methods: Our single-center cohort prospective study included a total of 117 consecutively operated patients presenting with significant concomitant carotid and coronary artery disease. All patients underwent surgery at the Clinic of Faculty Surgery of the Samara State Medical University, being symptomatic in both carotid and coronary circulations. They were subdivided into two groups depending on the staging of surgical treatment: 42 patients were subjected to one-stage surgical intervention [carotid endarterectomy (CEA) + coronary artery bypass grafting (CABG) during single anesthesia] and the remaining 75 patients underwent two-stage surgery (CEA at the first stage, followed by CABG performed within not more than a 3-month period). The groups were comparable by most parameters. The primary endpoints were stroke and myocardial infarction, as well as mortality from stroke and mortality from myocardial infarction in the perioperative period.

Results: There were no significant statistical differences in the incidence of myocardial infarction, stroke, and perioperative mortality between the two groups (p>0.05). A risk factor significantly associated with perioperative stroke appeared to be the presence of transitory ischemic attacks (TIAs) during 6 months before surgery (OR 18.400; 95% CI, p=0.002). Risk factors for perioperative myocardial infarction were the occurrence of postoperative bleeding and resternotomy (OR 12,333; 95% CI, p=0.021). A risk factor for patient death was the presence of TIAs within 6 months before surgery (OR 7.360; 95% CI, p=0.019).

Conclusions: Two-stage or one-stage surgical tactics in symptomatic patients with significant ICA and coronary artery disease had similar rates of perioperative myocardial infarctions, cerebrovascular events, and mortality. The main risk factors for the development of adverse outcomes in these patients were the presence of TIA during 6 months before surgery, as well as postoperative bleeding combined with resternotomy.

Background: In the structure of surgical events, acute limb ischemia is a cause of death in 25-30% of patients.

Objective: The present study was aimed at examining the structure of patients with lower and upper limb acute ischemia in the Barnaul urban agglomeration.

Patients and methods: We analyzed a total of 1,366 patients presenting with arterial embolism or limb thrombosis within 14 days after the onset of the acute event and hospitalized to the Department of Vascular Surgery during 2000-2018. The epidemiological index of acute limb ischemia amounted to 10.1 per 100 thousand people per year, being comparable with the data of the international statistics. Of these, 865 patients were hospitalized during 2000-2010, and 501 during 2011-2018.

Results: Comparing the groups demonstrated an increased number of hospitalizations of women (from 4.6 to 5.3 per 100 thousand/year) in the structure of all patients with acute ischemia, a statistically significant decrease in the number of patients with arterial thromboses, and an increase in the number of those admitted with arterial embolisms. We revealed a tendency to a decrease in the overall number of hospitalized patients and an increase in the number of patients with stage II-III arterial ischemia, with upper limb ischemia diagnosed significantly more often (from 1.4. to 3.2 per 100 thousand/year).

Conclusion: Along with a trend towards a decrease in the total number of hospitalized patients with acute limb ischemia, we revealed an increase in the number of patients with acute limb ischemia in the presence of arterial embolism and a decreased number of patients with acute arterial thrombosis.